MEDICAL POLICY SUBJECT: SPINAL INJECTIONS (EPIDURAL AND FACET INJECTIONS) FOR PAIN MANAGEMENT

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1 MEDICAL POLICY SUBJECT: SPINAL INJECTIONS (EPIDURAL AND PAGE: 1 OF: 10 If a product excludes coverage for a service, it is not covered, and medical policy criteria do not apply. If a commercial product (including an Essential Plan product) or a Medicaid product covers a specific service, medical policy criteria apply to the benefit. If a Medicare product covers a specific service, and there is no national or local Medicare coverage decision for the service, medical policy criteria apply to the benefit. POLICY STATEMENT: I. Based upon our criteria and assessment of peer-reviewed literature, facet joint injections/medial branch blocks) have been medically proven to be effective and therefore, medically appropriate for facet mediated pain resulting from disease, injury or surgery and confirmed by provocative testing resulting in reproducible pain (i.e., hyperextension, rotation) that has not responded sufficiently to at least four (4) weeks of conservative therapy (exercise, physical methods including physical therapy, chiropractic care, NSAIDs and/or analgesics). II. Based upon our criteria and assessment of the peer-reviewed literature, facet joint injections/medial branch blocks does not improve patient outcomes and is not medically necessary for neck pain or low back pain in the absence of an untreated radiculopathy. III. Based upon our criteria and assessment of the peer-reviewed literature, an initial diagnostic facet joint injection/medial branch block has been medically proven to be effective and therefore, medically appropriate to determine whether chronic neck or back pain is of facet joint origin when ALL of the following criteria are met: A. Pain is exacerbated by extension and rotation, or is associated with lumbar rigidity B. Pain has persisted despite appropriate conservative treatment (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs, exercise) C. Clinical findings and imaging studies suggest no other obvious cause of the pain (e.g., spinal stenosis, disc degeneration or herniation, infection, tumor, fracture). IV. Based upon our criteria and assessment of the peer-reviewed literature, a second diagnostic facet joint injection/medial branch block has been medically proven to be effective and therefore, medically appropriate when the first diagnostic facet joint injection/medial branch block is positive. V. Based upon our criteria and assessment of the peer-reviewed literature, a second diagnostic facet joint injection/medial branch block has been medically proven to be effective and therefore, medically appropriate no sooner than one week following the initial diagnostic facet joint injection/medial branch block VI. Based upon our criteria and assessment of the peer-reviewed literature, in order to avoid coming to an improper diagnosis or providing unnecessary treatment, facet joint injections/medial branch blocks performed on the same day as other spinal injections in the same region do not improve patient outcomes and are considered not medically necessary. VII. Based upon our criteria and assessment of peer-reviewed literature, facet joint injections/medial branch blocks have been medically proven to be effective and therefore, medically appropriate when the same level or levels are injected bilaterally during the same session/procedure. VIII. Based upon our criteria and assessment of the peer-reviewed literature, facet joint injections/medial branch blocks do not improve patient outcomes and are not medically necessary when performed on more than three (3) levels during the same session/procedure. IX. Based upon our criteria and assessment of the peer-reviewed literature, facet joint injections/medial branch blocks do not improve patient outcomes and are not medically necessary for the routine use of intravenous sedation as this A nonprofit independent licensee of the BlueCross BlueShield Association

2 PAGE: 2 OF: 10 can expose individuals to potential complications. The use of intravenous sedation may be grounds to negate the results of a diagnostic block and; therefore, should be reserved for only those individuals with severe anxiety issues. X. Based upon our criteria and assessment of the peer-reviewed literature, a second diagnostic facet joint injections/medial branch blocks do not improve patient outcomes and are not medically necessary when the first diagnostic facet joint injection/medial branch block has not been not positive. XI. Based upon our criteria and assessment of the peer-reviewed literature, therapeutic facet joint injections/medial branch blocks have not been medically proven to be effective and are considered investigational. XII. Based upon our criteria and assessment of the peer-reviewed literature, facet joint injections/medial branch blocks do not improve patient outcomes and are not medically necessary in clinical situations where radiofrequency joint denervation/ablation procedures (facet neurotomy, facet rhizotomy) are not being considered. XIII. Based upon our criteria and assessment of the peer-reviewed literature, epidural steroid injection without the use of fluoroscopic guidance and the injection of a contrast do not improve patient outcomes and are not medically necessary with the exception of an emergent situation or when fluoroscopy or the injection of contrast is contraindicated. XIV. Based upon our criteria and assessment of the peer-reviewed literature, epidural steroid injection do not improve patient outcomes and are not medically necessary when administered for axial spinal pain without documentation of radiculopathy, myelopathy or myeloradiculopathy. XV. Based upon our criteria and assessment of the peer-reviewed literature, a caudal epidural steroid injection for levels above L4-L5 do not improve patient outcomes and are not medically necessary without a supporting clinical rationale (why it is preferred over translaminar or transforaminal, e.g., status post fusion with anatomical limitations) for alternative approaches. XVI. Based upon our criteria and assessment of the peer-reviewed literature, repeat epidural steroid injections do not improve patient outcomes and are not medically necessary when there is an absence of ANY of the following for > two week duration: A. At least 50% pain relief B. Increase in the level of function (i.e., return to work) C. Reduction in the use of pain medication and/or additional medical services such as physical therapy/chiropractic care XVII. Based upon our criteria and the lack of peer-reviewed literature, epidural steroid injection with ultrasound guidance for any indication. has not been medically proven to be effective and is considered not medically necessary. XVIII. Based upon our criteria and assessment of the peer-reviewed literature, epidural steroid injection has been medically proven to be effective and therefore, medically necessary for presumed radiculopathy or radiculitis resulting from disease, injury or surgery that has not responded sufficiently to a reasonable course (four week minimum) of conservative treatment (exercise, physical methods including physical therapy and/or chiropractic care, NSAID s and/or muscle relaxants). XIX. Based upon our criteria and assessment of the peer-reviewed literature, epidural steroid injection has been medically proven to be effective and therefore, medically necessary for presumed radicular pain that follows a specified dermatomal distribution of an involved named spinal root(s), with or without motor (muscle)weakness, when there is a positive straight leg raise and/or crossed leg raise test and the individual has not responded sufficiently to a reasonable course (four week minimum) of conservative treatment (exercise, physical methods including physical therapy and/or chiropractic care, NSAID s and/or muscle relaxants).

3 PAGE: 3 OF: 10 XX. Based upon our criteria and assessment of the peer-reviewed literature epidural steroid injection do not improve patient outcomes and are not medically necessary when the service is performed on the same day as other spinal injections in the same region. XXI. Based upon our criteria and assessment of the peer-reviewed literature epidural steroid injection do not improve patient outcomes and are not medically necessary when performed in isolation without the individual participating in an active rehabilitation program/home exercise program/functional restoration program. XXII. Based upon our criteria and assessment of the peer-reviewed literature, epidural steroid injection has been medically proven to be effective and therefore, medically necessary as an initial trial in an individual with evidence of symptomatic spinal stenosis who meets ALL of the following criteria: A. Diagnostic evaluation has ruled out other potential causes of pain; B. MRI or CT with or without myelography within the past twelve (12) months demonstrates severe spinal stenosis at the level to be treated; C. Significant functional limitations resulting in diminished quality of life and impaired, age-appropriate activities of daily living; and D. Failure of at least four (4) weeks of conservative treatment (e.g., exercise, physical methods including physical therapy and/or chiropractic care, NSAID s and/or muscle relaxants). Refer to Corporate Medical Policy # , Radiofrequency Facet Denervation. POLICY GUIDELINES: I. Positive diagnostic medial branch block or facet joint injection using either a local anesthetic or a local anesthetic combined with corticosteroid as evidenced by either of the following: A. A beneficial clinical response to an intra-articular facet injection or medial branch block performed with a local anesthetic with greater than 80% pain relief reported for the duration of the effect of the local anesthetic when no corticosteroids are added to the injectate B. A beneficial clinical response to an intra-articular facet joint injection or medial branch block performed with a local anesthetic and a corticosteroid with at least a 50% reduction in pain for at least two (2) weeks. II. No more than two diagnostic facet joint injections/medial branch block may be required to determine whether back pain originates in the facet joint or nerves surrounding the facet joint. Subsequent facet injections/medial branch blocks are considered to be therapeutic rather than diagnostic. III. Facet joint injections/medial branch blocks can expose individuals to potential complications. Diagnostic facet joint injections/medial branch blocks should therefore only be performed with the anticipation that if successful, radiofrequency joint denervation/ablation procedures (facet neurotomy, facet rhizotomy) would be considered as an option at the diagnosed levels. IV. The use of an indwelling catheter to administer a continuous infusion/intermittent bolus should be limited to use in a hospital setting only. It is inappropriate to represent the use of a catheter for single episode injection(s) that is/are commonly performed in an outpatient setting as an indwelling catheter for continuous infusion/intermittent bolus. V. No more than three (3) epidural steroid injections should be performed per episode of pain and no more than four (4) injections per region per year. VI. There is insufficient scientific evidence to support the scheduling of a series-of-three epidural steroid injections in either a diagnostic or therapeutic approach. The medical necessity of subsequent injections should be evaluated individually and be based on the response of the individual to the previous injection with regard to clinically relevant sustained reductions in pain, decreased need for medication and improvement in the individual s functional abilities.

4 PAGE: 4 OF: 10 VII. When performing transforaminal epidural steroid injeciton, no more than two (2) nerve root levels should be injected during the same session/procedure. When performing an interlaminarepidural steroid injection, no more than one (1) interlaminar level should be injected during the same session/procedure. VIII. The Federal Employee Health Benefit Program (FEHBP/FEP) requires that procedures, devices or laboratory tests approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational and thus these procedures, devices or laboratory tests may be assessed only on the basis of their medical necessity. DESCRIPTION: Low back pain is a common concern, affecting up to 90% of Americans at some point in their lifetime. Back pain is not a specific disease, but rather it is a symptom that may occur from a variety of different processes. Back pain can be divided into three classifications: axial or mechanical back pain, referred pain and radicular pain. Axial pain is localized to the back. Usually certain activities aggravate the condition and rest makes it better. This is the most common type of back pain and usually gets better with conservative treatments. Conservative treatment may include pharmacological therapy (e.g., analgesics, anti-inflammatory drugs, and muscle relaxants), exercise, spinal manipulation, acupuncture, cognitive-behavioral therapy, yoga, acupuncture, massage, and physical therapy. Referred pain is a dull achy pain that extends from the back into the extremities along the nerve path. The pain can move, vary in intensity and be sporadic. As with axial pain, treatment is usually simple, non-invasive techniques. Radicular pain is described as a deep, steady pain that radiates from the back into the extremities and is associated with particular activities such as standing, walking or sitting. Numbness, tingling and muscle weakness may accompany the pain. Sciatica is the most common version of radicular pain. Radicular pain is usually related to a compressed, inflamed nerve in the spine due to disc herniation, spinal stenosis or nerve root damage. Management of back pain that is persistent and disabling despite the use of recommended conservative treatment is challenging. Epidural injections and facet joint injections using local an anesthetic and/or steroids have been employed in the treatment of back pain as an alternative to more invasive interventions. An epidural injection is an injection into the epidural space, which is the area which surrounds the spinal cord and the nerves coming out of it. The goal of an epidural injection is to relieve pain, improve function, and reduce the need for surgical intervention by reducing inflammation and relieving inflammation-associated pressure. Epidural injections may be performed using caudal, interlaminar or transforaminal approaches. Transforaminal epidural injections, also referred to as selective nerve root blocks, are performed using fluoroscopy guidance in order to increase the accuracy of needle placement, avoid accidental intravascular injection, and ensure visualization of anatomical anomalies. Facet joint injections/facet blocks (e.g., medial branch blocks) have been used to treat back pain and/or to help determine whether the facet joint is a source of pain. Facet joints (i.e., zygapophysial joints) are located in the posterior compartment of the spinal column, and provide stability and allow the spine to bend and twist. Facet joints are well innervated by the medial branches of the dorsal rami, and can be subjected to significant strain during spine loading. Degenerative changes in the posterior lumber facet joints have been established as a source of LBP that may radiate to the leg. Pain impulses from the medial branches of lumbar dorsal rami can be interrupted by blocking these nerves with anesthetic (facet block) or coagulating them with a radiofrequency wave (radiofrequency facet denervation). Typically, facet joint blocks are performed as a part of a work-up for back or neck pain. Pain relief following a precise injection of local anesthetic confirms the facet joint as the source of pain. Based on the outcome of a facet joint nerve block, if the patient gets sufficient relief of pain but the pain recurs, denervation of the facet joint may be considered. For determining a precise location for injection therapy and to avoid complications, spinal injections have been performed primarily by fluoroscopic or computed tomographic (CT) guidance. Recently, ultrasound guided injections have been explored.

5 PAGE: 5 OF: 10 RATIONALE: Epidural injections Overall, the evidence for the use of diagnostic and therapeutic injections in the treatment of acute and chronic back pain is limited. Clinical studies have demonstrated that epidural steroid injections have provided short-term improvement and may be considered in the treatment of selected patients with radicular pain as part of an active therapy program. There is insufficient evidence to demonstrate that epidural steroid injections are effective in the treatment of back pain in the absence of radicular symptoms. Buenaventura and colleagues (2009) conducted a systematic review to evaluate the effectiveness of lumbar transforaminal epidural injections in managing chronic radicular pain. Of the 4 randomized controlled trials evaluating transforaminal epidural steroid injections, all showed positive results for short-term relief; 2 studies were positive for long-term relief; the results for long-term relief were not available in 1 and one study had negative long-term relief results. Abdi et al. (2007) conducted a systemic review of published trials and abstracts of scientific meetings, published between January 1966 and October 2006, to determine the efficacy and safety of epidural steroid injections (ESIs). The primary outcome measure was pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. They identified 11 randomized trials of lumbar interlaminar ESI. Of these studies, 8 had favorable results for short-term (less than 6 weeks) relief and 1 was positive for long-term (6 weeks) relief. The level of evidence for interlaminar ESIs was considered strong for short-term pain relief and limited for longterm pain relief. There were 7 randomized trials of lumbar transforaminal ESI (TFESI), 5 of which had favorable results for both short- and long-term pain relief. The level of evidence for TFESI was considered strong for short-term pain relief and moderate for long-term pain relief. Of the 8 randomized trials of caudal ESIs, 5 had favorable results for shortterm pain relief and 4 had favorable results for long-term pain relief. The level of evidence for caudal epidural injections was considered strong for short-term relief and moderate for long-term relief. The 2007 American College of Occupational and Environmental Medicine evidence-based practice guidelines on low back disorders state that epidural glucocorticosteroid injections are an option for acute or subacute radicular pain syndromes. The injection may provide short-term improvement to allow time to determine whether conservative care will succeed. Epidural steroid injections may be appropriate for radicular pain syndromes lasting at least three weeks, when there is no evidence of trending towards spontaneous resolution following treatment with NSAIDs. The guideline also states that epidural steroid injections may be considered as a second-line treatment for acute flare-ups of spinal stenosis, when symptoms have persisted for one to two months despite treatment with NSAIDs and exercise. Epidural steroid injections are not recommended for acute, subacute, or chronic low back pain in the absence of significant radicular symptoms. Novak, et al. (2008) conducted a systematic review to evaluate the evidence in support of guidelines on frequency and timing of epidural steroid injections in order to help determine what sort of response should occur to repeat an injection. The review included 11 randomized controlled trials, one prospective controlled trial, and two prospective cohort studies. The authors stated that many of the problems with this type of research stem from a lack of understanding of the underlying mechanisms of radicular pain and a lack of understanding of how epidural steroid injections provide an effect. The underlying mechanism of glucocorticoid activity is not clearly understood, and there is no indication for repeat injection based solely on the characteristics of the medication itself. The authors concluded that there is limited evidence to suggest guidelines for frequency and timing of epidural steroid injections or to help define an appropriate partial response that would trigger a repeat injection. Research suggests that repeat injections may improve outcomes, but conclusions cannot be made due to methodological limitations of the available evidence. The authors concluded that there does not appear to be any evidence to support the common practice of a series of injections. The American Pain Society s evidenced-based clinical practice guideline based on the systematic review by R Chou and colleagues (2009) noted the following: It is recommended that interdisciplinary rehabilitation be considered as a

6 PAGE: 6 OF: 10 treatment option for persistent, disabling low back pain that does not respond to usual, non-interdisciplinary therapies. For persistent non-radicular low back pain, facet joint corticosteroid injection, prolotherapy, and intradiscal corticosteroid injection are not recommended, and there is insufficient evidence to reliably guide recommendations on use of other interventional therapies. A shared decision-making process including a detailed discussion of risks, moderate average benefits, and treatment alternatives is recommended to guide decisions regarding surgery. For radicular low back pain, a shared decision-making process including a detailed discussion of risks and inconsistent evidence regarding short-term benefits is recommended to guide decisions regarding epidural steroid injection. A shared decision-making process is also recommended to guide decisions regarding surgery for spinal stenosis and prolapsed lumbar disc, though supporting evidence is stronger than for surgery for non-radicular low back pain. The results of a systematic review by AT Parr and colleagues (2012) evaluating the effect of caudal epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain has shown good evidence for short- and long-term relief of chronic pain secondary to disc herniation or radiculitis with local anesthetic and steroids and fair relief with local anesthetic only. Further, this systematic review also provided only fair evidence for caudal epidural injections in managing chronic axial or discogenic pain, spinal stenosis, and post-surgery syndrome. Facet injections Generally, the outcomes from clinical studies show a diagnostic facet joint injection may assist in determining whether specific interventions targeting the facet joint are indicated. There is insufficient evidence to demonstrate that therapeutic facet joint injections are effective in the treatment of back pain, however. Guidelines from the American Pain Society (Chou, et al. 2009) note that there is fair to good quality evidence that facet joint injections are not effective. Guidelines from the American Association of Neurological Surgeons state that facet injections are not recommended as long-term treatment for chronic low-back pain. Guidelines from the American College of Occupational and Environmental Medicine state that therapeutic facet joint injections for acute, subacute, chronic low back pain or radicular pain syndrome are not recommended. An assessment by the Canadian Agency for Drugs and Technologies in Health (updated 2011) concluded that evidence of the safety and efficacy of therapeutic facet joint injections for low back pain was lacking and of low quality. They also noted conflicting evidence related to the efficacy of diagnostic facet joint injections. Use of ultrasonic guidance There is no evidence in the peer-reviewed literature regarding the overall health benefit of the use of ultrasonic guidance during spinal injections over the use of fluoroscopy or CT-guidance. CODES: Number Description Eligibility for reimbursement is based upon the benefits set forth in the member s subscriber contract. CODES MAY NOT BE COVERED UNDER ALL CIRCUMSTANCES. PLEASE READ THE POLICY AND GUIDELINES STATEMENTS CAREFULLY. Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently than policy updates. Code Key: Experimental/Investigational = (E/I), Not medically necessary/ appropriate = (NMN). CPT: Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance with imaging guidance (e.g., CT or fluoroscopy)

7 PAGE: 7 OF: Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance with imaging guidance (e.g., CT or fluoroscopy) ICD10: Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic (code range) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral (code range) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic (code range) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral (code range) 0213T-0218T (NMN) 0228T-0231T (NMN) Multiple diagnosis codes Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance (code range) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance (code range) Copyright 2018 American Medical Association, Chicago, IL

8 PAGE: 8 OF: 10 REFERENCES: Agency for Healthcare Research and Quality (AHRQ). Technology assessment. Pain management therapies for low back pain Mar [ accessed 3/31/17. Bhatia A, et al. Transforaminal epidural steroid injections for treating lumbosacral radicular pain from herniated intervertebral discs: a systematic review and meta-analysis. Anesth Analg 2016 March;122(3): Bicket MC, et al. Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the control injections in randomized controlled trials. Anesthesiology 2013 Oct;119(4): BlueCross BlueShield Association. Epidural Steroid Injection for Back Pain. Medical Policy Reference Manual # Nov 12. Boswell MV, et al. A Best-evidence systematic appraisal of the diagnostic accuracy and utility of facet (zygapophysial) joint injections in chronic spinal pain. Pain Physician 2015 Jul-Aug;18(4):E Bui J and Bogduke N. A systematic review of the effectiveness of CT-guided, lumbar transforaminal injection of steroids. Pain Med 2013 Dec;14(12): Bureau NJ, et al. Transforaminal versus intra-articular facet corticosteroid injections for the treatment of cervical radiculopathy: A randomized, double-blind, controlled study. AJNR Am J Neuroradiol 2014 May 29 [Epub ahead of print]. Canadian Agency of Drugs and technologies in Health (CADTH). Health Technology Assessment. Facet joint injection as diagnostic and therapeutic tools for pain of the cervical and lumbar spine: a review of clinical and cost-effectiveness. [ accessed 3/31/17. Chang-Chien GC, et al. Transforaminal versus interlaminar approaches to epidural steroid injections: a systematic review of comparative studies for lumbosacral radicular pain. Pain Physician 2014 Jul-Aug;17(4):E Choi JH, et al. What is the role of epidural steroid injections in lumbar spinal disease with moderate disability. Pain Physician 2016 May;19(4): Chou R, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and metaanalysis. Ann Intern Med 2015 Sep 1;163(5): Cohen SP, et al. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology 2014 Nov;121(5): Cohen SP, et al. Epidural steroids: a comprehensive, evidence-based review. Reg Anesth Pain Med 2013 May- Jun;38(3): Cohen SP, et al. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ 2015 Apr 16;350:h1748. Davis N, et al. Transforaminal epidural steroid injection in lumbar spinal stenosis: an observational study with two-year follow-up. Br J Neurosurg 2017 April;31(2): Derby R, et al. Indications for repeat diagnostic medical branch nerve blocks following a failed first medical branch nerve block. Pain Physician 2013 Sep-Oct;16(5): Engel A, et al. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med 2014 Mar;15(3): Friedly JL, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 2014 Jul 3;371(1):11-21.

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10 PAGE: 10 OF: 10 [ accessed 3/30/17. North American Spine Society. Coverage policy recommendations. Lumbar epidural injections. Dec 2014 [ accessed 3/30/17. North American Spine Society. Coverage policy recommendations. Facet joint interventions. Dec 2014 [ accessed 3/30/17. Pountos I, et al. Safety of epidural corticosteroid injections. Drugs R D 2016 March;16(1): Rathmell JP, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology 2015 May;122(5): *Savegh FE, et al. Efficacy of steroid and nonsteroid caudal epidural injections for low back pain and sciatica: a prospective, randomized, double-blind clinical trial. Spine 2009 Jun 15;34(14): Shim E, et al. Facet joint injection versus epidural steroid injection for lumbar spinal stenosis: intra-individual study. Clin Radiol 2017 Jan;72(1):96.e7-96.e14. Spijker-Huiges A, et al. Epidural steroids for lumbosacral radicular syndrome compared to usual care: quality of life and cost utility in general practice. Arch Phys Med Rehabil 2015 Mar;96(3): Vekaria R, et al. Intra-articular facet joint injections for low back pain: a systematic review. Eur Spine J 2016 Apr;25(4): Wu T, et al. Effectiveness of ultrasound-guided versus fluoroscopy or computed tomography scanning guidance in lumbar facet joint injections in adults with facet joint syndrome: a meta-analysis of controlled trials. Arch Phys Med Rehabil 2015 Dec 17 [Epub ahead of print]. * key article KEY WORDS: Epidural injection, Facet injection, Injection therapy, Medical branch block, Spinal injection, Ultrasound-guidance CMS COVERAGE FOR MEDICARE PRODUCT MEMBERS There are currently Local Coverage Determinations (LCD) for facet injections and lumbar epidural injections. Please refer to the following LCD websites for Medicare Members: Facet injections: al+government+services%2c+inc.+(13201%2c+a+and+b+and+hhh+mac%2c+j+- +K)&s=All&DocType=Active&bc=AggAAAQAAAAAAA%3d%3d&#0 Lumbar epidural injections: +Government+Services%2c+Inc.+(13201%2c+A+and+B+and+HHH+MAC%2c+J+- +K)&s=All&DocType=Active&bc=AggAAAQAAAAAAA%3d%3d&